Peritoneal Dialysis Patients Awaiting Renal Transplantation

17 February 1968 Kwashiorkor and Marasmus-Phillips and Wharton MICALJOURNAL 409

to all children with kwashiorkor is of doubtful value. Aroutine antibiotic such as tetracycline might be used, but sincehalf of the children had no infection, and antibiotics may haveserious side-effects, and since, moreover, it is difficult to devisea universal "umbrella," the value of routine antibioticregimens is questionable.

Bacteriological evidence of infection should always be soughtbefore antibiotics are prescribed, and we believe that the routineuse of antibiotics in kwashiorkor may lead to a false sense ofsecurity and to diagnostic and therapeutic dilemmas.

However, bacteriological services are rarely available wherekwashiorkor abounds, and therefore we make the following sug-gestions. Urine should be examined for pus cells. Pyuriashould be confirmed by examination of a suprapubic samplewhere possible. Antibiotics should be prescribed only if thereis some clinical indication of a particular infection-forexample, of the skin, chest, throat, or blood stream. Diarrhoeais only occasionally due to a specific organism. Since it isusually impossible to distinguish clinically between infectiveand non-infective diarrhoea, a working rule might be to giveantibiotics to those children with particularly severe diarrhoea(say more than six stools a day) or in whom a complicatingsepticaemia is suspected because of a high pyrexia or hypo-thermia, a "soft" spleen, a rapidly falling haemoglobin, or" warm hypotension " in an already very sick child.

SummaryAbout half the children admitted to this unit with severe

malnutrition had an acute bacterial infection.Gram-negative infections of the urinary tract, or gut, and

septicaemia were particularly troublesome, while Gram-positiveinfections gave less cause for concern. The cause of most ofthe chest infections remains unknown.

Penicillin would have been appropriate for only a few infec-tions, and if a routine antibiotic is thought to be necessarytetracycline would be better. There are, however, pertinent

arguments against the routine use of antibiotics, and bacterio-logical evidence of infection should be sought wherever possiblebefore the antibiotics are prescribed.

If bacteriological services are not available antibiotics shouldbe given only if there is clinical indication of a particularinfection-for example, of the skin, chest, throat, gut orblood stream.

Mr. R. Fernandes gave valuable technical assistance, and Dr.H. C. Chapman and Sisters A. Court, E. Strange, C. Roberts, G.Crewe, M. Hood, and S. Mukasa helped in the care of the childrenand the collection of specimens. We are grateful to all of them,and to Professor R. A. McCance and Professor R. Blowers for theiradvice.

Requests for reprints should be addressed to M.R.C. InfantileMalnutrition Research Unit, P.O. Box 7051, Kampala, Uganda.

REFERENCES

&har, M., Viteri, F., and Scrimshaw, N. S. (1957), Anmer. 7. clin. NuLt.,5, 506.

Brenton, D. P., Brown, R. E., and Wharton, B. A. (1967). Lancet, 1,410.

Brown, R. E. (1965). Trop. geogr. Med., 17, 289.Campbell, J. A. H. (1956). Arch. Dis. Childh., 31, 310.Davies, J. N. P. (1948). E. Afr. med. Y., 2S, 228.Dean, R. F. A. (1965). In Recent Advances of Paediatrics, edited by D.

Gairdner, 3rd ed., p. 234. London.and Swanne, J. (1963). 7. trop. Pediat., 8, 97.

de Silva, C. C. (1964). Advanc. Pediat., 13, 213.Garrow, J. S., Picou, D., and Waterlow, J. C. (1962). West Indian med.

7., 11, 217.Hansen, J. D. L. (1961). In Recent Advances in Human Nutrition, edited

by J. F. Brock, p. 267. London.Hesiod (c. 700 s.C.). Works and Days, edited by T. A. Sinclair, 1932.

London.McCance, R. A. (1951). In Spec. Rep. Ser. Med. Res. Counc. (Lond.),

No. 275, p. 21.Newman, C. G. H., O'Neill, P., and Parker, A. (1967). Brit. med. 7.,

2, 277.Piburn, M. F. (1960). Cent. Afr. 7. Med., 6, 149.Smythe, P. M. (1958). Lancet, 2, 724.- and Campbell, J. A. H. (1959). S. Afr. med. 7. 33, 777.

Stirling, G. A. (1962). Arch. Dis. Childh., 37, 378.Wharton, B. A. (1966). E. Afr. med. 7., 43, 570.Wharton, B. A., Balmer, S., Somers, K., and Templeton, A. C. (1967).

In preparation.

Prolonged Peritoneal Dialysis in Patients Awaiting Renal Transplantation

S. L. COHEN,* M.B., B.S., M.R.C.P.; A. PERCIVALt M.A., B.M., B.CH.

Brit. med. J., 1968, 1, 409-413

The value of peritoneal dialysis when used for short periodsin the management of patients suffering from acute renal fail-ure is well established (Maxwell et al., 1959 ; Burns et al.,1962). Peritoneal dialysis carried out for more prolongedperiods in patients with chronic irreversible renal failure hasbeen relatively little. studied (Boen et al., 1964; Lasker et al.,1965). Compared with haemodialysis, peritoneal dialysis hasthe advantage that a number of patients can be managed ingeneral medical wards without capital expenditure or the needfor a special unit and specially trained nursing and technicalstaff. For this reason peritoneal dialysis was used in patientsawaiting human cadaver renal transplantation, though haemo-dialysis is preferred for this purpose by most other groups.Because of the difficulties in obtaining suitable donor kidneyssome patients have had to wait for months before transplan-

* Senior Registrar, Medical Unit. St. Mary's Hospital, London W.2.t Lecturer in Bacteriology, St. Mary's Hospital Medical School, London

W.2. Present address: Department of Bacteriology, University ofLiverpool, Liverpool 3.

tation, and this is a report of our experience of peritonealdialysis for periods of two to seven months.

Patients and MethodsDetails of the 27 patients who received peritoneal dialysis

for more than two months are shown in Table I. They were

TABLE I.-Details of L' Patients Receiving Prolonged Peritoneal Dialysis

Age {Range 8-46 yearsAeMean.28-6fMale 16SeOemalc .... . . 11

Snderly aChronic gloneruloIephrids 13Underlyng J Chronic pyelonephritis 9disease Polycystic disease 2dsaeiOthers' . .3

Period on {Range .60-219 daysdialysis L Mean 104 days

Previous dialysis at other hospitals 11Period Range ............. .. .. . 14-119 days

Period {R5flgCMean 54 days* Acute glomerulonephritis 1, congenital hyperoWaluria 1, and primary hyper-

tensive nephrosclerosis 1.

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410 17 February 1968selected for transplantation by criteria previously described(Mowbray et al., 1965). In all of them renal function wasinadequate to maintain life without dialysis (endogenouscreatinine clearance less than 2 ml. per minute).

Patients were managed in two general medical wards and weregiven a high-protein diet without restriction of fluid or salt.They all received intensive physiotherapy and were encouragedto spend as much time as possible outside hospital. Initially,peritoneal dialysis was performed on alternate nights between7 p.m. and 6 a.m., with the patient off dialysis during the dayand spending free nights at home. Before transplantationpatients were started on a low dose of azathioprine (1-1.5mg./kg./day) and were then dialysed every night to minimizethe toxic effects of this therapy. Blood urea and plasmaelectrolytes were estimated at least twice weekly.

Dialysis ProcedureThe dialysis procedure was based on that described by

Maxwell et al. (1959) and Thomson et al. (1964). With fullaseptic precautions a catheter was introduced into the peri-toneal cavity through the midline about 1 in. (2.5 cm.) belowthe umbilicus. During 1966 the Trocath catheter (McGawLabs. Inc.) .(Weston and Roberts, 1965) was used because thestylet within its lumen requires a much smaller skin incisionthan catheters introduced through a cannula. The catheterwas anchored by a single pursestring suture surrounded bysterile dry gauze swabs and covered with a dressing of Micro-pore Surgical Tape. The swabs and dressing were changeddaily. Catheters were changed only when it became impossibleto remove obstructing particles by syringing or when theybecame dislodged. The suture was reinserted as soon as itbecame displaced. The dialysis solution was a standard com-mercially available one, Dialaflex (Allen and Hanburys).Composition.-Solution 141 mEq/l. ; chloride 100.8 mEq/l.;

calcium 3.6 mEq/l.; magnesium 1.5 mEq/l.; bicarbonate (aslactate) 44.6 mEq/l.; dextrose 1.36% or 6.36%. Mixtures ofthe two glucose concentrations were used to control fluidbalance.Heparin was added to the solution at a concentration of

1,000 units per litre, and if serum potassium levels fell below3.5 mEq/l. potassium chloride was also added to the dialysisfluid until the hypokalaemia was corrected. All additions weremade immediately before use.In order to minimize the introduction of viable bacteria

every disconnexion of or injection into the dialysis system waspreceded by five minutes' exposure of the involved surfaces to*.5% chlorhexidine in 70% alcohol. For all such manipula-tions attendant staff used an aseptic technique.The dialysis fluid was introduced through a Dialaflex giving

set, with two spearheads, each inserted into a 1-1. plastic bagaf dialysis fluid. The drainage tube was secured with its tipin the neck of a Winchester bottle in which the dialysiseffluent was collected. Initially, 50 ml. of 0.5% chlorhexidinein 70% alcohol was added to the collection bottle as a disin-fectant, but 1 ml. of 40% formaldehyde solution was usedinstead after it had been discovered that the chlorhexidinetended to be inactivated by the protein in the dialysis effluent.In adults 2 1. and in children 1 1. of dialysis fluid was usedfor each exchange. The fluid was not warmed and wasallowed to run into the peritoneal cavity over a 15-minuteperiod. It was retained for 30 minutes and then allowed todrain out for a further 30 minutes. The volume of dialysiseffluent was measured and recorded. Between exchanges thegiving set spearheads and, when not in use, the tip of thedrainage tube were immersed in 0.5% chlorhexidine in 70%alcohol. Seven exchanges were usually performed during thenight, and afterwards the administration set was discarded andthe indwelling peritoneal catheter sealed with a steriledisposable plastic spigot in the end of the connecting tube.

Peritoneal Dialysis-Cohen and Percival BurnMEDICAL JOURNAL

Control and Treatment of InfectionA sample of peritoneal dialysis effluent was collected daily.

approximately 15 ml. was centrifuged at 1,500 r.p.m. for 15minutes, and the deposit cultured and examined micro-scopically. A diagnosis of peritoneal infection was establishedonly when polymorphs and organisms were seen in the depositand the causative organism was isolated. When Gram-stainedfilms suggested the presence of infection direct sensitivitytesting was carried out on the deposit, using impregnatedpaper discs, and, if possible, the results after an eight-hourincubation were reported the same evening so that appro-priate treatment could be initiated if the patient had developedsymptoms. If the patient remained asymptomatic treatmentwas withheld until the following day, when the results ofculture were known and a further specimen of dialysis fluidwas available for examination. If this confirmed the presenceof infection treatment was initiated, regardless of the presenceor absence of symptoms. Swabs were taken twice weekly forculture from the skin around the peritoneal catheter and fromthe nose and throat. Infecting organisms were identified bystandard methods, and all. strains of Staphylococcus aureuswere phage-typed and strains of Pseudomonas aeruginosapyocine typed by the method of Gilles and Govan (1966).The skin around the peritoneal catheter was treated daily

with antimicrobial substances. Initially, nystatin dustingpowder (Squibb) and an antibiotic aerosol containing poly-myxin B, neomycin, and bacitracin were used, but most peri-toneal infections still seemed to be caused by organismsresiding in this area. Subsequently, chlorhexidine cream or

dusting powder was used and the patients had daily bathswith the catheter site exposed; 25 ml. of a 10% solution ofhexachlorophane was added to the bath-water. In patientsfound to be carrying Staph. aureus in the nasopharynx a cream

containing neomycin and chlorhexidine was applied to theanterior nares twice daily for 10 days. Antibiotics were not

routinely incorporated in the peritoneal dialysis fluid.Bactericidal antibiotics were used for treatment of peritoneal

infection and were administered by incorporation in the peri-toneal dialysis fluid, usually at an approximate concentrationof 25 or 50 ptg./ml. for 7 to 14 days, depending on the clinicalresponse and the nature of the infecting organism. Patientswith severe infections were also given oral or systemic anti-biotic for the first two or three days of treatment, which was

then adjusted to produce serum levels of antibiotic thatexceeded the minimum inhibitory concentration for the infec-ting organism (Percival and Cohen, 1967).

Results

The results of prolonged peritoneal dialysis are summarizedin Table II. This shows that there was a considerableimprovement during the second year of the study. Of the 27patients 25 were subsequently transplanted. Sixteen were

well and active during the entire dialysis period and five didwell initially but deteriorated after two to four months. Twoof these died-one of peritonitis and one of postoperativehaemorrhage after the repair of a catheter-induced bowel

TABLE II.-Response of 27 Patients to Prolonged Peitoneal Dialysis

No. Classification of Response =Studied Good* Deterioratedt Poor* Died§

1965 11 4 (36%) 2(18%) 4(36%) 1(9%)1966 16 12 (75%) 1(6%) 2(13%) 1 (6%)Total 27 16(59%) 3(11%) 6 (22%) 2 (7%)

* Active, free from major complications, and spending most of the day out of

hospital.t Initially did well but later became inactive owing to complications.* Never free from complications.S One patient died from peritoneal infection and the other from bowel perforation

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17 February 1968 Peritoneal Dialysis-Cohen and Percival

perforation. Failure of peritoneal dialysis in another patientnecessitated haemodialysis until she was transplanted. Sixpatients, all subsequently transplanted, were never very wellwhile on peritoneal dialysis.

Fluid and Electrolyte Control

The initial effect of peritoneal dialysis in removing excessfluid in renal failure and in correcting electrolyte imbalanceis well known (Boen, 1961). For this reason the changesoccurring in the first week are excluded.The mean change in weight for the entire group over the

whole period on dialysis (excluding the first week) was-1.5 kg. (range -20 to + 12 kg.).Control of blood urea and electrolytes was achieved in all

cases (Table III), but the blood urea level did not correlatewith general well-being or frequency of complications. Tenpatients had intermittent hyperkalaemia (K>6 mEq/L.), whichusually was related to dietary intake and occurred after a fewweeks of dialysis. This group were treated with an ion-exchange resin, Resonium-A, orally or rectally when required.

TABLE III.-Effect of Peritoneal Dialysis on Blood Urea

Blood urea (mg.100 ml.)* . 100 101-125 126-150 151-175Number ofpatients .. .7 8 7 5

0 Mean for period on dialysis excluding the first week.

Serum Proteins

The changes in serum proteins were observed during adialysis period of between 4 and 26 weeks in 17 patients, andare shown in Table IV. Slight ankle oedema apparently dueto hypoproteinaemia occurred in only two patients, after fourto five months of dialysis, but there were no other manifesta-tions of hypoproteinaemia in any of the patients.

TABLE IV.-Effect of Peritoneal Dialysis on Serum Proteins

I~Serum Proteins (g./100 ml.)Initial Final Change

Range Mean Range Mean Range Mean

Total . . 7-1-3-8 5-5 6-2-3-7 5-1 + 1-2 to-1-7 -0 4Albumin 39-1-4 2-7 3-41-4 2-4 + 1-0 to - 1-0 - 03

Hypertension

Control of hypertension was facilitated within one monthof beginning peritoneal dialysis in 21 of the 26 patients whowere hypertensive (Table V). Blood pressure returned tonormal without the use of hypotensive drugs in four patients.A reduced dosage of hypotensive drugs was sufficient to main-tain normal blood pressure in four patients, and to improvecontrol of hypertension considerably in another 13. Bloodpressure was unaffected in the remaining five, but two of themwere only mildly hypertensive. Hypertension was uncontrollablein one patient until bilateral nephrectomy was performed. Afterthis his blood pressure was controlled by peritoneal dialysisalone. There was a close relation between improved controlof hypertension and loss in body weight. An example is shownin Table VI.

TABLE V.-Effect of Peritoneal Dialysis on HypertensionNo. ofPatients

Blood pressure returned to normal .8Without hypotensive drugs . .4With hypotensive drugs at reduced dosage. 4

Improved control with reduced dosage of hypotensive drugs 1 3Unaffected. 5

TABLE VI.-Relation Between Weight Loss and Hypertension in a

Patient on Peritoneal Dialysis

Periodon

Dialysis

Initially . .

I week ..

2 weeks . .

3 ,. .4 ,5 ,

Weight Weight(g) Lost

(kg.)

60

59

57534743

37

13

17

Mean*B.P.

(mm./Hg)

190/125

140/80

180/105175/100140/80115/70

Dosage per Day

Reserpine 1 mg., spironolactone300 mg., chlorothbazide 1 g.

Bethanidine 30 mg., spironolac-tone 300 mg., chlorothiazide05 g.

Methyldopa 750 mg.1,lg.

None" 1g.

* Blood pressure is the weekly mean of all observations, both standing and lying.

Neurological

Peripheral neuropathy was present in 12 patients on ad-mission. In two dialysis resulted in marked improvement intheir sensory changes. There was no progression of neuro-pathy in eight of the other 10, but in two the condition becameprogressively worse during 11 and 16 weeks of dialysis.

Psychiatric

Psychiatric complications occurred in six patients. Fourbecame depressed, but two of these were known to have haddepressive personalities before they became uraemic. Inanother patient depression followed an episode of cardiac arrest,and in the remaining patient depression was associated witha breakdown in her marriage. An acute anxiety state devel-oped after six months on dialysis in one patient, and a boyof 14 became withdrawn and regressed to an infantile patternof behaviour after one month on dialysis.

MechanicalThe average life of the catheter was eight weeks and of the

catheter anchoring suture one month. In one case the catheterlasted seven months. Previously described mechanical com-plications, such as catheter blockage, intermittent problemswith fluid drainage, leakage of fluid, and extraperitonealsubcutaneous extravasation, occurred rarely. In no instancewas there any difficulty in correcting these complications.Four patients complained of persistent nausea, which was not

relieved by antiemetics. Respiratory embarrassment occurredin only one patient, and that during the first exchange (Berlyneet al., 1966). Pain sufficient to prevent the patients fromsleeping during the dialysis or to warrant the administrationof analgesics occurred in association with some episodes ofperitoneal infection, but rarely at other times.One patient suffered from haemorrhage from the abdominal

wall when the catheter was first inserted, and had to be trans-fused with 4 pints (2.3 1.) of blood. In two patients who hadsuffered repeated episodes of peritoneal infection bowelperforation occurred during reinsertion of a peritoneal cathe-ter. This led to the death of one and to maintenance byhaemodialysis in the other.

Cardiovascular

Postural hypotension was troublesome in eight patients,including three who were not receiving hypotensive therapy.It was most pronounced in the morning soon after the end ofthe dialysis period. Both pericarditis and congestive cardiacfailure, present on admission in many patients, rapidlyresolved within a few days of starting peritoneal dialysis. Twopatients developed pericarditis after two months' dialysis, butthis resolved within a week without specific treatment.

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Anaci

All patients were anaemic initially. Transfusions weregiven when progressive symptoms of anaemia appeared, or ifthe haemoglobin fell below 5.6 g./100 ml. The mean haemo-globin level for the whole group during the period on dialysiswas 8.7 g./100 ml. On average, patients received 9 pints (5 1.)of blood during every 100 days on dialysis. Patients werealways dialysed throughout the blood transfusion to preventprecipitation of cardiac failure.

Peritoneal Infection

During the study period the frequency of peritoneal infec-don was considerably reduced, the average rate of infectionbeing once in every 32 days of dialysis during the first yearbut only once in 77 days of dialysis during the second year.Three patients remained free from peritoneal infection duringperiods of 62, 158, and 180 days of dialysis. Fifty-sevenepisodes of infection occurred in the other 24 patients: 10had one episode, 6 had two, 3 had three, 2 had four, and oneeach of three patients had five, six, and seven episodes respec-tively. The majority of infections were caused by Staph.albus or Staph. aureus (Table VII), and in 70% of all infec-tions the same organism was isolated from the skin aroundthe peritoneal catheter within a few days before the onset ofinfection. Symptoms were minimal or absent in many of theinfections caused by less pathogenic organisms such as Staph.albus, but infection by Staph. aureus and the Gram-negativeorganisms was usually associated with abdominal pain andfever above 100° F. (37.80 C.), and blood culture was positivein 15%.

TABLE VII.-Organisms Causing Peritoneal Infeaions in PatientsReceiving Prolonged Peritoneal Dialysis

Number of InfectionsOrgnism First Subsequent Total

Episode Episodes Total

Staphylococcus albus .. .. 14 (58%) 12 (36%) 26 (46%)aureus .. .. 6 (25%) 4 (12%) 10 (17%)

Adinetobacter anitratwn . 5 5Escherichia coli I 2 3Proteus mirabilis 1 2 3Streptococcus faecalis 1 2 3Ps. ae0uginosa . . 0 2 2Others 1 . ... . , ..45

Total .. 24 33 57

One each of Sir. pyogenes, Str. viridans, Bacillus cereus, Klebsiella aerogenes, andCandida albicans.

Thirty-six infections were eradicated by a single 7-to-14-daycourse of an appropriate antimicrobial agent. In 20 episodesinfection by the same organism occurred within two weeks ofstopping treatment, but, because of the persistence of theinfecting organism on the skin, around the peritoneal catheterit was not possible in some instances to determine whetherthis was failure of treatment or reinfection. In five staphylo-coccal infections which failed to respond to treatment withcloxacillin or cephaloridine further investigation showed thatthe organisms were " cloxacillin-resistant " staphylococci,though initial sensitivity testing by the paper disc method hadindicated that the organisms were sensitive (Percival andCohen, 1967). Despite treatment one patient died fromperitonitis and bacteraemia due to Ps. aeruginosa after 62days of dialysis.

Discussion

At present the major limiting factor in treating patients withirreversible renal failure by cadaveric transplantation is thedifficulty in obtaining suitable donor kidneys. Patients mayhave to be maintained for many months in a condition suitable

for transplantation at any time, and for this purpose haemo-dialysis is usually preferred to peritoneal dialysis, mainlybecause of the high incidence of peritonitis associated withperitoneal dialysis (Bower and Hume, 1965). In the casesdescribed here the rate of peritoneal infection was reducedby more than 50% during the study period to once in every77 days of peritoneal dialysis. Three patients were dialysedfor between two and seven months without developing peri-toneal infection, and a further 10 suffered only one episode ofinfection. Many of the infections were associated with mini-mal symptoms and responded readily to antimicrobial treat-met without cessation of peritoneal dialysis. Only one patientdied from peritonitis, but in two patients recurrent infectioneventually caused peritoneal adhesions with subsequent bowelperforation during reinsertion of the peritoneal catheter.Bowel perforation is probably an indication for transferralof the patient to haemodialysis. The two perforations whichoccurred were repaired immediately.The majority of peritoneal infections were caused by staphylo-

cocci (Table VII), and in 70% of all infections the sameorganism was isolated from the skin around the catheter siteduring the few days before the onset of the infection. Therehave also been four peritoneal infections, including one in acase described here, due to B. cereus, which was found to bea contaminant in the nystatin dusting powder applied to theskin around the peritoneal catheter. Though it has beensupposed that the endogenous intestinal flora is the mainsource of peritoneal infection (Schwartz et at., 1967), thesefindings suggest that in our patients infecting organismsusually gained entry to the peritoneal cavity by passingthrough the abdominal wall around the peritoneal catheter.Organisms could also have been introduced along the lumenof the peritoneal catheter, particularly during syringing torelieve obstruction, but care to maintain sterility of thedialysis connexions may have reduced the incidence ofexogenous infection. It is unlikely that the skin around theperitoneal catheter can be rendered sterile for long periods.Nevertheless, we attempted to minimize the number of organ-isms residing in this area.The changes in procedure associated with the reduction in

peritoneal infection during the study period were the use ofchlorhexidine cream around the peritoneal catheter insteadof antibiotic spray, allowing the patients to have frequentbaths, and the substitution of formaldehyde for chlorhexidineas the disinfectant in the container of the dialysis effluent.Unfortunately, cream rendered the skin around the peritonealcatheter soggy and was discarded in favour of chlorhexidinepowder.In this study peritoneal infection was always associated with

increased turbidity of the peritoneal dialysate (Lasker et al.,1965), but turbidity due to increase in the number of whitecells commonly occurred without bacterial infection. Becausedaily microscopy and culture of peritoneal dialysate createsadditional work for the laboratory, it might be thought suffi-cient to examine the dialysate only when this is observed tobe turbid. However, before beginning the study we hadseen two patients with peritonitis due to resistant Gram-negative organisms who died before isolation and sensitivitytesting of the causative organism enabled the appropriateantibiotic to be selected and given. To prevent this happeningit would be necessary to begin treatment of all symptomaticinfections with wide-spectrum antibiotics, which have toxicside-effects (Lasker et al., 1965). We found that daily exam-ination of the dialysate allowed specific treatment to beinitiated at an early stage, which was thought advisable inorder to minimize the risks of fatal complications and thedevelopment of peritoneal adhesions. On a number of occa-

sions bacteria were isolated from asymptomatic patients, butthe next day's specimen was sterile, and no antibacterial treat-ment was given.

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17 February 1968 Peritoneal Dialysis-Cohen and Percival BEDIHoU 413Loss of protein in the peritoneal dialysate has been reported

to cause complications due to hypoproteinaemia in patientsundergoing prolonged peritoneal dialysis (Berlyne et al., 1964),but the fall in serum proteins in our patients was slight(Table IV), in part because the patients were given a high-protein diet.

In 21 of the 26 patients who were hypertensive the controlof hypertension was facilitated by peritoneal dialysis, withoutdietary salt-and-water restriction (Kolff et al., 1964) or hypo-natraemic dialysis (Moriarty and Parsons, 1966; Palmer et al.,1966). The mechanism of this effect is uncertain, though aclose relation between changes in body weight and in bloodpressure (Hegstrom et al., 1962) was found in our patients(Table VI). Even in the absence of oedema or cardiac failurehypertensive patients with chronic renal failure have excesstotal body sodium with expanded total body water and extra-cellular fluid. It would have been difficult to restrict salt andwater without reducing protein intake, but fortunately suchunpleasant measures were not found necessary.Because of different selection criteria and varying periods

of observation it is difficult to obtain comparative figures forhaemodialysis and peritoneal dialysis. The mortality rate ofa group of 68 patients maintained by haemodialysis beforetransplantation was 11 % in one study (Bower and Hume,1965), and in another study (Abella et al., 1967) 43% ofpatients maintained for prolonged periods, mainly by haemo-dialysis, were thought to be well controlled. Sixteen of ourpatients (59%) were well controlled, but two (7.4%) diedbefore transplantation. Though peritoneal dialysis is widelyrecognized as the treatment of choice for short-term use inacute renal failure (Cameron, 1966), opinions vary regardingits value over prolonged periods (Schribner et al., 1965Moriarty and Parsons, 1966; Palmer et al., 1966). Our resultsshow that many patients can be well controlled by peritonealdialysis for periods of up to seven months. With the sametechniques smooth and efficient control of the dialysis ofpatients with acute renal failure in our hospital is also ob-tained. At any one time at least eight patients were managedin two general medical wards. We estimate that this requiredone-third of a medical registrar's and one-half of a laboratorytechnician's time. During the nights on dialysis in the two22-bedded wards the nursing coverage of each ward consistedof either one State-registered nurse who had recently qualified,one student nurse, and one nursing auxiliary, or two studentnurses and one nursing auxiliary.

Summary

Twenty-seven patients with irreversible renal failure andawaiting renal transplantation were maintained by peritonealdialysis for periods of between two and seven months. Six-

teen (59%) were well and active during the entire dialysisperiod. Five did well initially but deteriorated because ofcomplications, which proved fatal in two patients. Six patientswere never well while on peritoneal dialysis, but all weresubsequently transplanted.

Control of blood urea and electrolytes was achieved in allpatients, and control of hypertension was facilitated in 21 ofthe 26 hypertensive patients without restriction of salt orwater. A high-protein diet was given and the fall in serumproteins during the dialysis period was only slight.During the study the average rate of peritoneal infection

was reduced from once in every 32 to once in every 77 daysof dialysis. Measures were taken to minimize peritonealinfection.

We wish to thank Professor W. S. Peart and Dr. J. F. Mowbrayfor permission to describe the management of patients under theircare and for their help and advice. We thank all the nursing staffand the many hospital departments concerned.

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Boen, S. T. (1961). Medicine (Baltimore), 40, 243.- Mion, C. M., Curtis, F. K., and Shilipetar, G. (1964). Trans. Amer.

Soc. artil. intern. Organs, 10, 409.Bower, J. D., and Huame, D. M. (1965). Ibid., 11, 225.Burns, R. O., Henderson, L. W., Hager, E. B., and Merrill, J. P. (1962).

New Engl. 7. Med, 267, 1060.Cameron, J. S. (1966). Brit. med. f., 2, 811.Gillies, R. R., and Govan, J. R. W. (1966). 7. Path. Bact., 91, 339.Hegstrom, R. M., Murray, J. S., Pendras, J. P., Burnell, J. M., and

Scribner, B. H. (1962). Trans. Amer. Soc. artit. intern. Organs, 3,266.

Kolff, W. J., Nakamoto, S., Poutasse, E. F Straffon, R. A., and Figueros,J. E. (1964). Circulation, 30, Suppl. II, p. 23.

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